Download Limbs

Mark Kozsurek
11/01/2010
Ver.1.9
Joints, muscles, vessels and nerves of the upper limb
Sternoclavicular joint
1. surfaces: sternal facet of clavicle and clavicular notch of manubrium of the sternum. Articular
surfaces are covered by fibrocartilage.
2. capsule: is attached to the margins of the articular surfaces, slack and thick.
3. ligaments: anterior and posterior sternoclavicular ligaments, interclavicular ligament,
costoclavicular ligament. The latter one is the main factor which limits the movements of the
joint.
4. special features: articular disk made of fibrocartilage. Usually completely divides the joint cavity
into two and adjusts the incongruity existing between the articulating surfaces of the sternum and
clavicle.
5. type: multiaxial joint with 3 principal axes
a) sagittal axis: elevation and depression
ELEVATION
trapezius (superior part)
levator scapulae
rhomboid major et minor
DEPRESSION
trapezius (inferior part)
pectoralis minor
serratus anterior (inferior part)
b) vertical axis: protraction and retraction
PROTRACTION
pectoralis minor
serratus anterior
RETRACTION
trapezius
rhomboid major et minor
c) transverse axis: rotation (around the longitudinal axis of the clavicle) The role of this axis
and movements around it are negligible.
Acromioclavicular joint
1. surfaces: acromial facet of clavicle and clavicular facet of acromion of the scapula. Surfaces are
covered by fibrocartilage.
2. capsule: relatively loose, attached to the margins of the articular surfaces.
3. ligaments: coracoclavicular ligament, consisting of the trapezoid and conoid ligaments. These
ligaments strengthen the joint and limit its motions as well.
4. special features: articular disk made of fibrocartilage, usually incomplete, wedge-shaped.
5. type: multiaxial joint with three degrees of freedom. All movement in the sternoclavicular joint
are followed by motions in the acromioclavicular joint and this compensatory movement ensures
that the scapula remains always more or less parallel to the dorsal surface of the thoracic wall. The
most important is the
sagittal axis: rotation elevating and depressing glenoid fossa
ROTATION ELEVATING GLENOID FOSSA
serratus anterior
trapezius
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Mark Kozsurek
11/01/2010
Ver.1.9
ROTATION DEPRESSING GLENOID FOSSA
pectoralis minor
levator scapulae
rhomboid minor and major
Glenuhumeral joint (shoulder joint)
1. surfaces: head of humerus and the glenoid cavity of scapula, each surface is covered by hyaline
cartilage.
2. capsule: is attached to the margins of the articular surfaces (glenoid cavity medially and the
anatomical neck of humerus laterally), incorporates the supraglenoid tubercle where from the long
head of the biceps brachii arises. Capsule has three recesses: i) synovial sheath for the tendon of
the long head of biceps brachii in the intertubercular groove, ii) subscapular recess inferior to the
coracoid process communicating with the subscapular bursa and the largest iii) axillary recess.
3. ligaments: coracohumeral ligament, coracoacromial ligament. The latter one together with the
acromion and coracoid process forms a protecting arch over the head of humerus which prevents
the superior displacement of the head from the shallow socket. Abduction of the arm is limited by
the acromioclavicular ligament to the horizontal position, larger abduction requires the rotation of
the scapula and thus the elevation of the glenoid cavity (acromioclavicular joint).
4. special features: glenoid lip or labrum, a fibrocartilaginous ring what deepends slightly the
shallow glenoid cavity.
5. type: multiaxial joint with 3 principal axes
a) sagittal axis: abduction and adduction
ABDUCTION
deltoid (central part)
supraspinatus
ADDUCTION
pectoralis major
latissimus dorsi
infraspinatus
teres minor
b) transverse axis: anteversion (flexion) and retroversion (extension)
ANTEVERSION
pectoralis major (clavicular part)
deltoid (anterior fibers)
coracobrachialis
biceps brachii
RETROVERSION
latissimus dorsi
deltoid (posterior part)
teres major
c) longitudinal axis: medial and lateral rotation
MEDIAL ROTATION
subscapularis
latissimus dorsi
deltoid (anterior part)
teres major
pectoralis major
LATERAL ROTATION
deltoid (posterior part)
infraspinatus
supraspinatus
teres minor
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Mark Kozsurek
11/01/2010
Ver.1.9
Considering the shallow socket and the lack of strong ligaments stabilizing the joint, the head is kept in
place by the surrounding muscles forming the rotator cuff (SITS: supraspinatus, infraspinatus, teres
minor, subscapularis - all the muscles inserting on the greater or lesser tubercles).
Muscles acting upon the joints of the shoulder girdle
A) Dorsal (posterior) thoracoappendicular muscles
trapezius
origin: a line extending from the external occipital
protuberance to the spinous process of 12th thoracic
vertebra
insertion: spine of scapula, acromion, clavicle
innervation: accessory nerve (XI. cranial nerve)
latissimus dorsi
origin: iliac crest, inferior ribs and thoracic vertebrae,
thoracodorsal fascia
insertion: crest of lesser tubercle of humerus
innervation: thoracodorsal nerve
rhomboids
origin: spinous processes of C6-7 and T1-4 vertebrae
insertion: medial margin of scapula
innervation: dorsal scapular nerve
levator scapulae
origin: transverse processes of C1-4 vertebrae
insertion: superior angle of scapula
innervation: dorsal scapular nerve
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Ver.1.9
B) Ventral (anterior) thoracoappendicular muscles
pectoralis major
origin: medial part of clavicle, sternum, superior six costal
cartilages and aponeurosis of external oblique muscle
insertion: crest of greater tubercle
innervation: pectoral nerves
pectoralis minor
origin: 3-5th ribs
insertion: coracoid process
innervation: pectoral nerves
subclavius
origin: 1st rib, medially
insertion: clavicle, laterally-inferiorly
innervation: subclavian nerve
serratus anterior
origin: 1-9th ribs,laterally
insertion: medial margin of scapula
innervation: long thoracic nerve
C) Intrinsic shoulder or scapulohumeral muscles
deltoid
origin: clavicle, acromion, spine of scapula
insertion: deltoid tuberosity
innervation: axillary nerve
supraspinatus
origin: supraspinous fossa
insertion: greater tubercle
innervation: suprascapular nerve
infraspinatus
origin: infraspinous fossa
insetion: greater tubercle
innervation: suprascapular nerve
teres major
origin: inferior angle of scapula
insertion: crest of lesser tubercle
innervation: subscapular nerve
teres minor
origin: lateral margin of infraspinous fossa
insertion: greater tubercle
innervation: axillary nerve
subscapularis
origin: subscapular fossa
insertion: lesser tubercle
(Teres major inserts together with latissimus dorsi!)
innervation: subscapular nerve
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Mark Kozsurek
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Ver.1.9
Elbow joint
A compound joint constituted by 3+1 articulations
1. surfaces:
a. humeroradial joint: capitulum of humerus and fovea of the head of radius
b. humeroulnar joint: trochle of humerus and trochlear notch of ulna
c. proximal radioulnar joint: articular circumference of radius and radial notch of ulna
completed by the hyaline cartilage-covered inner surface of the anular ligament
d. distal radioulnar joint: articular circumference of ulna and ulnar notch of radius. Although
this joint is far from the elbow, functionally can not be separated from that.
2. capsule: more or less attached to the margins of the articular surfaces, but also envelops the
olecranon, radial and coronoid fossae. The ventral part of the capsule is extremly strong and thus,
it is the main factor which limits extension.
3. ligaments: radial and ulnar collateral ligaments, anular ligament of radius (serves as a socket for
the articular circumference of radius, see above!)
4. type: biaxial, pivotal-hinge (or trochoginglymus) subtype with two axes:
a. transverse axis: flexion and extension
FLEXION
biceps brachii
brachialis
EXTENSION
triceps brachii
b. longitudinal axis: pronation and supination
PRONATION
pronator teres
pronator quadratus
SUPINATION
biceps brachii
supinator
Muscles acting upon the elbow joint
The muscles of the arm mainly act on the elbow. Flexor (anterior) and extensor (posterior) compartments
are separated by the medial and lateral intermuscular septa and are invested by the brachial fascia.
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Mark Kozsurek
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Ver.1.9
A) Flexors of the arm
biceps brachii
origin: short head – coracoid process
long head – supraglenoid tubercle
insertion: tuberosity of radius
brachialis
origin: anterior surface of humerus
insertion: tuberosity of ulna
coracobrachialis
origin: coracoid process
insertion: distal portion of the medial margin of humerus
B) Extensors of the arm
triceps brachii
origin: long head – infraglenoid tubercle
medial and lateral heads – posterior surface of humerus
insertion: olecranon
anconeus
Might be considered as the fourth head of the triceps
sunk down to the forarm.
All the flexors are innervated by the musculocutaneous nerve, while all the extensors are supplied by the
radial nerve!
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Mark Kozsurek
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Ver.1.9
Wrist (or radiocarpal) joint
1. surfaces: carpal articular surface of radius, articular disc attached to the distal end of the ulna and
the proximal row of carpals, including the scaphoid, lunate and triquetrum.
2. ligaments: dorsal and palmar radiocarpal ligaments,palmar ulnocarpal ligament, radial and
ulnar collateral ligaments.
3. type: biaxial or elipsoid joint with a dorsopalmar and a radioulnar axis
a. dorsopalmar axis: ulnar and radial deviation or ulnar and radial abduction
ULNAR DEVIATION
flexor carpi ulnaris together with the extensor carpi ulnaris
RADIAL DEVIATION
flexor carpi ulnaris together with the extensor carpi radialis longus
and brevis
b. radioulnar axis: palmarfexion (flexion) and dorsiflexion (extension)
PALMARFLEXION
flexor carpi radialis together with the flexor carpi ulnaris
palmaris longus
DORSIFLEXION
extensor carpi radialis longus and brevis together with the extensor
carpi ulnaris
Intercarpal joints
A compound joint consisting of the joints between the carpals of the proximal row, between carpals of the
distal row and joints between the proximal and distal row, the latter are called midcarpal joints.
Intercarpal joint allows a small amount of gliding only (amphiarthrosis), but increases the range of
movement of the wrist joint. The dorsal, palmar and interosseus intercarpal ligaments, the
pisohamate ligament have to be mentioned. The same muscles act on the intercarpal joints which were
listed at the wrist joint.
Carpometacarpal joint of the thumb
Saddle joint with two axes: abduction-adduction and opposition-reposition. The capsule is strong and
lacks supporting ligaments which would also limit the movements available in this joint.
ABDUCTION
abductor pollicis longus
abductor pollicis brevis
ADDUCTION
adductor pollicis
opponens policis
flexor pollicis brevis
OPPOSITION
opponens policis
flexor pollicis brevis
adductor pollicis
REPOSITION
extensor pollicis longus and brevis
abductor pollicis longus
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Mark Kozsurek
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Ver.1.9
Carpometacarpal joints II-V.
Rigid joint or amphiarthroses with negligible movements. Dorsal and palmar carpometacarpal
ligaments are notable. More or less the same muscles act upon them which were mentioned at the wrist
and intercarpal joints.
Metacarpophalangeal joints II-V.
Spheroid joint with three possible axes, but active movement is only available in two of them: flexion
(palmarflexion) – extension (dorsiflexion) and abduction – adduction (in relation to the axis of the middle
finger). Rotation around the long axis of the metacarpals and proximal phalanges may be carried out
passively. The deep transvers metacarpal ligaments must be mentuioned, which interconnect the capsules
of the individual joints.
PALMARFLEXION
flexor digitorum superficialis and profundus
DORSIFLEXION
extensor digitorum
extensor digiti minimi
extensor indicis
ABDUCTION
dorsal interossei
ADDUCTION
palmar interossei
Metacarpophalangeal joint of thumb and all the interphalangeal joints
Hinge joint (or ginglymus) with collateral and palmar ligaments, dorsally lax capsules and with flexion
- extension only.
FLEXION
flexor digitorum superficialis and profundus
flexor pollicis longus
thumb only!
flexor pollicis brevis
EXTENSION
extensor digitorum
extensor digiti minimi
extensor indicis
extensor pollicis longus and brevis – thumb only!
Note: lumbricals extend in the interphalangeal and flect in the metacarpophalangeal joints!
Muscles acting upon the wrist joint and the joints of the hand
A) Flexors of the forarm
In general: the majority of the flexors of the forarm arises from around the medial epicondyle (if not, it
will be noted). Flexors form a superficial (1st and 2nd layers on the figure) and a deep layer (3rd and 4th
layers on the figure). The flexors are innervated by the median nerve excluding the ulnar portion of the
flexor digitorum profundus and flexor carpi ulnaris, the latter ones are supplied by the ulnar nerve.
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SUPERFICIAL
pronator teres
insertion: proximal one-third of the radius
flexor carpi radialis
insertion: base of 2nd metacarpal
palmaris longus
insertion: palmar aponeurosis
flexor digitorum superficialis
insertion: bases of 2nd -5th middle phalanges
flexor carpi ulnaris
insertion: pisiform, hamate and base of 5th metacarpal
11/01/2010
Ver.1.9
DEEP
flexor pollicis longus
origin: anterior surface of radius
insertion: base of distal phalanx of the thumb
flexor digitorum profundus
origin: anterior surface of ulna
insertion: bases of 2nd-5th distal phalanges
pronator quadratus
origin: ulna, distally and medially
insertion: radius, anterior surface
B) Extensors of the forarm
Superficial radial and superficial ulnar groups might be defined which are separated by the muscles of the
deep group. Majority of them arise from the lateral epicondyle and all of them are supplied by the radial
nerve.
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Mark Kozsurek
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SUPERFICIAL RADIAL
brachioradialis
insertion: styloid process of radius
extensor cari radiais longus
insertion: base of 2nd metacarpal
extensor carpi radialis brevis
insertion: base of 3rd metacarpal
SUPERFICIAL ULNAR
extensor digitorum
insertion: bases of 2nd-5th middle and distal phalanges
extensor digiti minimi
insertion: dorsal tendon of the little finger
extensor carpi ulnaris
insertion: base of 5th metacarpal
Ver.1.9
DEEP
supinator
origin: lateral epicondyle, proximal end of ulna
insertion: neck of radius
abductor pollicis longus
origin: middle portion of ulna, interosseous membrane
insertion: base of metacarpal of the thumb
extensor pollicis brevis
origin: middle portion of the radius, interosseous membrane
insertion: base of proximal phalanx of the thumb
extensor pollicis longus
origin: middle portion of the ulna, interosseous membrane
insertion: base of distal phalanx of the thumb
extensor indicis
origin: distal portion of the ulna
insertion: dorsal tendon of the index finger
Muscles of the hand
A) Muscles of thenar
The majority of the thenar muscles arise from the radial carpals, except for the adductor pollicis which
originates from the entire length of the 3rd metacarpal. The insertion site is one of the sesamoid bones at
the carpometacarpal joint or in the case of the opponens pollicis the body of the 1st metacarpal (figure D).
Muscles of the hand are supplied by the ulnar and median nerves.
abductor pollicis (1)
opponens pollicis (15)
adductor pollicis with oblique (13) and transverse (11) heads
flexor pollicis brevis with superficial (6) and deep heads (7)
B) Muscles of hypothenar
palmaris brevis (7)
abductor digiti
minimi (9)
opponens digiti minimi (11)
flexor digiti
minimi (10)
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Compare this group of muscles with the thenar and note the similarities! The hypothenar muscles arise
from the ulnar carpals and the insertion site is the base of the 5th proximal phalanx or in the case of the
opponens digiti minimi the body of the 5th metacarpal (figure D). There is no adductor for the little finger,
its role (adduction, obviously) will be provided by the ulnar palmar interosseous muscle.
C) Muscles of mesothenar
Nothing can be added to the figures above, but please note, lumbricals extend in the interphalangeal and
flect in the metacarpophalangeal joints!
Vessels and nerves of the upper limb
The brachial artery is the major blood vessel of the upper limb, it is the continuation of the
axillary artery beyond the lower margin of teres major and latissimus dorsi muscles (which constitute the
posterior wall of the axillary fossa). On the arm it is found in the medial bicipital groove. Its first relevant
branch is the deep brachial artery which together with the radial nerve enters the extensor compartment
of the arm and runs down on the posterior surface of the humerus in the groove for radial nerve covered
by the three heads of the triceps brachii. More distally the deep brachial artery divides into the radial and
middle collateral arteries.
As the brachial artery continues down in the medial bicipital groove the superior and inferior
ulnar collateral arteries arise from it.
In the cubital fossa the brachial artery divides into the radial and ulnar arteries which run
down and can be recognised on the radial and ulnar sides of the forarm, respectively.
The common interosseous artery arises from the ulnar artery immediately below the level of
ulnar and radial tuberosities, then it divides into the anteror and posterior interosseus arteries runing
down on the anterior and posterior surfaces of the interosseous membrane, respectively.
The cubital arterial rete (the arterious nework around the elbow) is formed by the distal
branches of the radial and middle collateral arteries, the inferior ulnar collateral artery and the radial,
ulnar and interosseous recurrent arteries, which are the returning branches of the radial, ulnar and
common interosseous arteries, respectively.
The most distal branches of the radial and ulnar arteries will constitute the superficial and deep
palmar and the dorsal carpal arches.
The superficial palmar arch is formed predominantly by the ulnar artery, with a contribution
from the superficial palmar branch of the radial artery and is found between the palmar aponeurosis and
the tendons of flexor digitorum superficialis. Three common palmar digital arteries arise from the arch,
which near the level of the metacarpophalangeal joints divide into two proper palmar digital arteries.
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The deep palmar arch is usually formed mainly from the terminal part of the radial artery
(which crosses the floor of the snuff box and after piercing the first dorsal interoseous gets into the the
deep layer of the palm) with a contribution from the deep palmar branch of the ulnar artery. The deep
palmar arch lies upon the bases of the metacarpal bones and on the interossei of the hand, being covered
by the adductor pollicis muscle, the flexor tendons of the fingers, and the lumbricals of the hand. From
the deep palmar arch emerge the princeps pollicis artery and the three palmar metacarpal arteries.
The dorsal carpal arch is an anatomical term for the anastomosis of the dorsal carpal branch of
the radial artery and the dorsal carpal branch of the ulnar artery near the back of the wrist. The arch gives
off three dorsal metacarpal arteries.
Axillary nerve: can be easily recognised in the lateral axillary hiatus or quadrangular space where it
appears together with the posterior humeral circumflex artery. Supplies the deltoid and teres minor
muscles.
Musculocutaneous nerve: pierces the coracobrachialis, passes between the biceps brachii and brachialis,
finally reaches the lateral corner of the cubital fossa, from where it supplies the skin of the forarm as the
lateral antebrachial cutaneous nerve. It is responsible for the innervation of all the arm flexors.
Median nerve: arises with two roots from the medial and lateral fasciculi of the brachial plexus and can
be followed downward in the medial bicipital groove. At the level of the cubital fossa it is found in the
midline, while on the forarm coarses distally between the flexor digitorum superficialis and profundus.
Passes through the carpal canal. Supplies the majority of the forarm flexors (not including the flexor carpi
ulnaris and the ulnar portion of the flexor digitorum profundus), the thenar muscles (except for the deep
head of the flexor pollicis brevis and adductor pollicis) and two radial lumbricals.
Ulnar nerve: first it can be identified in the medial bicipital grrove, then pierces the medial intermuscular
septum and enters the extensor compartment of the arm. Can be easily identified at the medial epicondyle
of humerus where it runs in the groove for ulnar nerve. More distally it is situated in the flexor
compartment of the forarm together with the ulnar artery and veins. Enters the palm through the Guyon
canal. Supplies the flexor carpi ulnaris and the ulnar portion of the flexor digitorum profundus, all the
muscles of the hypothenar and mesothenar, the two ulnar lumbricals, the adductor pollicis and the deep
head of flexor pollicis brevis.
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Radial nerve: only its most proximal part can be observed in the medial bicipital groove as the nerve
enters the extensor compartment of the arm together with the deep brachial artery. On the posterior
surface of the humerus they might be found in the groove for radial artery. Twisting around the humerus
it finally reaches the lateral angle of the cubital fossa. Somewhat more distally it divides into a superficial
and a deep branch. The deep branch pierces the supinator and supplies the muscles of the extensor
compartment of the forarm. The superficial branch runs downward radially together with the radial artery.
The superficial branch supplies the skin only.
Crutial anatomical regions of the upper limb
A) Deltoideopectoral groove
A groove bounded by the pectoralis major and deltoid mucles and accomodates the cephalic vein. Might
be considered as the continuation of the lateral bicipital groove.
B) Axillary fossa
anterior wall: pectoralis major and minor
medial wall: serratus anterior
posterior wall: teres major, latissimus dorsi, subscapularis
lateral wall: surgical neck of humerus, short head of the biceps brachii and coracobrachialis
D) Triangular and quadrangular spaces
Lateral axillary hiatus / quadrangular space
teres major and minor, long head of triceps brachii, surgical
neck of humerus
- axillary nerve
- posterior humeral circumflex artery
Medial axillary hiatus / triangular space
teres major and minor, long head of triceps brachii
- scapular circumflex artery
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E) Lateral and medial bicipital grooves
Grooves separating the brachialis and biceps brachii muscles on the lateral and medial sides, respectively.
The lateral one contains the cephalic vein and continues upward as the deltoideopectoral grrove. Nerves
and vessels found in the medial bicipital groove: median nerve, ulnar nerve, median antebrachial
cutaneous nerve, brachial artery and veins, basilic vein, median brachial cutaneous nerve, radial nerve,
musculocutaneous nerve, superior and inferior ulnar collateral arteries.
F) Cubital fossa
The cubital fossa is the triangular area on the anterior view of the elbow. Superiorly it is bounded by an
imaginary horizontal line connecting the medial and lateral epicondyles of the humerus. The medial and
lateral borders are the brachioradialis and pronator teres muscles, respectively. The floor of the fossa is
formed by the brachialis and somewhat deeper by the supinator. The tendon of the biceps brachii devides
the cubital fossa into two and the medial half is covered superiorly by the bicipital aponeurosis arising
medially from the tendon and fusing with the cubital fascia. More important structures: brachial artery
branching into the ulnar and radial arteries, median nerve, radial nerve (in the lateral corner of the fossa).
G) “Anatomist’s snuff box”
A tringle-shaped area bounded radially by the abducor pollicis longus and extensor pollicis brevis (in the
1st synovial sheat), ulnarry by the extensor pollicis longus (3rd synovial sheat) and proximally by the
extensor retinaculum. The apex of the triangle is the metacerpophalangeal joint of the thumb. Deep in the
radial foveola the radial artery is found.
H) Palmar and dorsal carpal synovial sheats
1. Abductor pollicis longus
Extensor pollicis brevis
2. Extensor carpi radialis longus
Extensor carpi radialis brevis
3. Extensor pollicis longus
4. Extensor digitorum
Extensor indicis
5. Extensor digiti minimi
6. Extensor carpi ulnaris
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Joints, muscles, vessels and nerves of the lower limb
Hip joint
1. surfaces: head of femur and the lunate surface of the acetabulum
2. capsule: strong and loose, attaches proximally to the acetabulum and the transverse acetabular
ligament and distally to the intertrochanteric line on the anterior surface of the femur. Posteriorly
the fibrous capsule almost reaches the level of the intertrochanteric crest, but does not attach to it.
The synovial membrane protrudes here inferior to the fibrous capsule and forms the obturator
externus bursa. Deep fibers of the fibrous capsule passing circulary around the neck form the
orbicular zone.
3. ligaments: transverse acetabular ligament and the ligament of the head of the femur are the
internal ligaments of the joint. The former bridges the acetabular notch, while the latter one has no
mechanical role but contains an artery for the head of the femur. The external hip ligaments might
be considered as the thickest parts of the fibrous capsule and include the iliofemoral,
ischiofemoral and pubofemoral ligaments. All of them pass in a spiral fashion from the pelvis
to the femur. In the flected position of the hip these ligaments are loose and allow a wide range of
movement. When the joint is extended the ligaments twist around the neck tightly and screw the
head into the acetabulum, thus, restrict all the movements and make the joint much more rigid.
4. special features: acetabular labrum made of fibrocartilage. Joins the bony rim of the acetabulum
and the transverse acetabular ligament bridging the acetabular notch. Labrum increases the depth
of the acetabulum and grasps the head of the femur beyond its equator. For this reason neither the
capsule nor the ligaments of the joint nor the surrounding muscles are necessary to hold the head
in the socket! (Remember the shoulder joint, where the muscles of the rotator cuff are essential for
the stability.)
5. type: multiaxial joint (ball-and-socket type) with 3 principal axes
a) sagittal axis: adbuction and adduction
ABDUCTION
gluteus medius
gluteus minimus
tensor of fascia lata
ADDUCTION
muscles of the adductor compartment of the thigh
b) transverse axis: anteflexion (flexion) and retroflexion (extension)
ANTEFLEXION
iliopsoas
sartorius
rectus femoris
RETROFLEXION
gluteus maximus
hamstrings (semitendinosus, semimemranosus, biceps brachii)
c) longitudinal axis: medial and lateral rotation
MEDIAL ROTATION
gluteus medius
gluteus minimus
adductor magnus
LATERAL ROTATION
gluteus maximus
piriformis
gemellus superior and inferior
obturator externus and internus
quadratus femoris
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A) Internal hip muscles
iliopsoas
1. psoas major
2. psoas minor
origin: body and costal process of T12-L4 vertebrae
3. iliacus
origin: iliac fossa
insertion: the three parts together on the lesser trochanter
innervation: direct branches of the lumbar plexus
obturator internus
origin: internal surface of the obturator memrane and
surrounding bones
insertion: trochanteric fossa
innervation: direct branches of the sacral plexus
piriformis
origin: anterior surface of sacrum
insertion: trochanter major
innervation: direct branches of the sacral plexus
B) External hip muscles
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tensor of fascia lata
origin: anterior superior iliac spine
insertion: iliotibial tract
innervation: superior gluteal nerve
gluteus maximus
origin: behind the posterior gluteal line on the outer surface
of the wing of ilium, thoracolumbar fascia,
sacrotuberous ligament, dorsal ligaments of the
sacroiliac joint
insertion: gluteal tuberosity on the dorsal surface of femur,
iliotibial tract
innervation: inferior gluteal nerve
gluteus medius
origin: between posterior and anterior gluteal lines
insertion: trochanter major
innervation: superior gluteal nerve
gluteus minimus
origin: between anterior and inferior gluteal lines
insertion: trochanter major
innervation: superior gluteal nerve
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obturator externus
origin: outer surface of the obturator memrane and
surrounding bones
insertion: trochanteric fossa
innervation: obturator nerve
gemellus superior
origin: ischial spine
insertion: trochanteric fossa
innervation: sacral plexus
gemellus inferior
origin: ischial tuberosity
insertion: trochanteric fossa
innervation: sacral plexus
quadratus femoris
origin: ischial tuberosity
insertion: quadrate tubercle on the intertrochanteric crest
innervation: sacral plexus
C) Hip adductors (medial muscles of the thigh)
Pectineus
pectineus
origin: pecten pubis
insertion: pectineal line of the femur
adductor longus
origin: inferior to the pubic tubercle
insertion: middle third of linea aspera
adductor brevis
origin: inferior ramus of pubis
insertion: upper third of linea aspera
adductor magnus
origin: ramus of ischium, ischial tuberosity
insertion: from the gluteal tuberosity along the linea aspera
till the adductor tubercle
gracilis
origin: inferior ramus of pubis
insertion: pes anserinus, tibial tuberosity
All the adductors are supplied by the obturator nerve, but the pectineus is also innervated by the femoral
nerve.
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Knee joint
1. surfaces: lateral and medial condyles of the femur, the medial and lateral tibial plateaus and the
patella (fibula is not involved in the knee joint!).
2. capsule: thin and also deficient in some areas. Proximally attaches to the articular margins of the
femoral condyles and distally to the articular margins of the tibia. Fibrous capsule is deficient
postero-laterally to allow the tendon of the popliteus to pass out of the joint, and anteriorly where
the patella and patellar ligament serve as a capsule. The joint cavity extends superior to the patella
as the suprapatellar bursa, which lies between the anterior surface of the femur and the
quadriceps. Infrapatellar fat pad is found between the patellar ligament and retinacula and the
synovial mebrane. From here projects the infrapatellar synovial fold toward the intercondylar
fossa.
3. ligaments: The tibial collateral ligament is a flat band fused with the medial aspect of the
capsule and the medial meniscus.The fibular collateral ligament is rounded and strong, and is
independent from the lateral meniscus and the capsule. Collateral ligaments are tense in the
extended position of the joint. Anterior and posterior cruciate ligaments cross each other like
the letter X and provide stability for the knee especially when it is flected. Transverse ligament
of the knee interconnects the anterior ends of the two menisci. Oblique popliteal ligament might
also be mentioned as the extension of the flat tendon of the semimembranosus that strengthens the
capsule posteriorly.
4. special features: medial and lateral menisci made of fibrocartilage. They are crescent and in
transverse sections wedge-shaped. Medial is more gracile and C-shaped, while the lateral is more
roboust and almost circular. Menisci are able to glide on the tibial plateaus relatively freely as
only their ends are connected to the anterior and posterior intercondylar areas and their margins to
the fibrous capsule. The main role of menisci is the compensation of the incongruence existing
between the articulating surfaces (rounded femoral condyle and flat tibial plateau): when the joint
is extended they “open” and in flexed position they “close”.
5. type: basically hinge joint but in flected position a new axis appears around which further movents
become available, thus, can be considered as a pivot-hinge joint with 2 principal axes
a) transverse axis: flexion and extension
FLEXION
hamstrings
sartorius
gracilis
EXTENSION
quadriceps femoris
b) longitudinal axis: (only in flected position!!!) medial and lateral rotation
MEDIAL ROTATION
semitendinosus
semimembranosus
gracilis
sartorius
LATERAL ROTATION
biceps femoris
A) Extensors of the knee
sartorius
origin: anterior superior iliac spine
insertion: pes anserinus
quadriceps femoris
1) rectus femoris
origin: anterior inferior iliac spine
2-4) vastus medialis, intermedius and lateralis
origin: anterior surface of the femur
insertion: base of patella and the tibial tuberosity via the
patellar ligament
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B) Flexors of the knee
semitendinosus
origin: ischial tuberosity
insertion: pes anserinus
semimembranosus
origin: ischial tuberosity
insertion: radiates into the posterior capsule as the oblique
popliteal ligament
biceps femoris
1) long head
origin: ischial tuberosity
2) short head
origin: lateral lip of linea aspera, lateral intermuscular
septum
insertion: head of the fibula
All the flexors and extensors of the thigh are supplied by the sciatic and femoral nerves, respectively.
Joints of the foot
Talocrural
Subtalar
Talocalcaneonavicular
…
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A) Flexors of the leg
SUPERFICIAL
triceps surae
1) gastrocnemius medialis
origin: medial epicondyle of the femur
2) gastrocnemius lateralis
origin: lateral epicondyle of the femur
3) soleus
origin: head of fibula, soleal line of the tibia
4) plantaris
origin: lateral epicondyle of the femur
insertion: calcaneal tuber, via the Achilles
(or calcaneal) tendon
DEEP
popliteus
contributes to the capsule of the knee joint posteriorly
flexor hallucis longus
origin: distal portion of the fibula, interosseous membrane
insertion: distal phalanx of the big toe
flexor digitorum longus
origin: posterior surface of tibia
insertion: distal phalanges of 2nd - 5th toes
tibialis posterior
origin: posterior surface of tibia and fibula, interosseous membrane
insertion: navicular bone and adjacent ligaments
B) Extensors of the leg
tibialis anterior
origin: lateral condyle of tibia, fascia cruris
insertion: medial cuneiform, 1st metatarsal
extensor hallucis longus
origin: fibula, interosseous membrane
insertion: distal phalanx of the big toe
extensor digitorum longus
origin: lateral condyle of tibia, fibula, interosseous membrane, fascia
cruris
insertion: 2nd - 5th toes
(peroneus tertius)
a smaller part of the extensor digitorum longus inserting on the base of
the 5th metatarsal
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C) The peroneus compartment of the leg
peroneus longus
origin: head of fibula, intermuscular septa
insertion: medial cuneiform, 1st metatarsal
peroneus brevis
origin: fibula, intermuscular septa
insertion: base of 5th metatarsal
Muscles of the foot
Vessels and nerves of the lower limb
The femoral artery (the continuation of the external iliac artery from the inguinal ligament)
reaches the anterior surface of the thigh through the lacuna vasorum of the subinguinal hiatus, and then it
is recognizable in the iliopectineal fossa and somewhat more distally in the femoral triangle.
This is where its first prominent branch, the deep femoral artery arises. Close to its origin the
deep femoral artery branches to the medial and lateral circumflex femoral arteries which supply the
adductor and the extensor compartment, respectively. The main trunk of the deep femoral artery runs
down on the anterior surface of the adductor magnus and pierces the muscle with usually three
perforating branches which are then responsible for the blood supply of the flexor muscles.
On the anterior surface of the thigh after leaving the iliopectineal fossa and the femoral triangle
the femoral artery enters the adductor canal which is twisting medially and then posteriorly around the
thigh and terminates in the popliteal fossa with the adductor hiatus. Before reaching the popliteal fossa a
small branch pierces the vasto-adductor membrane together with the saphenous nerve and the descending
genicular artery becomes superficial and contributes to the arterious network around the knee.
From the adductor hiatus the artery is called popliteal artery and gives arise to several smaller
branches called middle, superior and inferior, medial and lateral genicular arteries, which also
contribute to the arterious network of the knee. The popliteal artery finally divides into the anterior and
posterior tibial arteries running down in the extensor and flexor compartments of the leg, respectively.
The continuation of the anterior tibial artery can be recognized on the dorsal surface of the
foot as the dorsalis pedis artery close to the tendon of extensor hallucis longus. The terminal branch of
the artery pierces the first interosseous space and forms the plantar arch together with the lateral plantar
artery.
The posterior tibial artery is found between the superficial and deep flexors of the leg and then
reaches the plantar region through the flexor retinaculum. The terminal branches are the medial and
lateral plantar arteries. The medial plantar artery is weaker, while the lateral one contributes to the
plantar arch.
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Taking together the plantar arch is composed of the dorsalis pedis artery and the lateral plantar
artery. Arising branches are called plantar metatarsal arteries, which distally continue as common
plantar digital arteries branching to proper plantar digital arteries at the roots of the toes.
Sciatic nerve: exits the pelvis through the infrapiriformis hiatus and runs downward on the posterior
surface of the superior gemellus, tendon of the obturator internus, inferior gemellus and quadratus
femoris. Then it is found in the flexor compartment of the thigh on the posterior surface of adductor
magnus. The sciatic nerve branches at a quite variable level into the tibial nerve and the common
peroneal (fibular) nerve. Tibial nerve can be recognized in the popliteal fossa, more distally it is located
in the flexor compartment of the leg between the superficial and deep flexors. The terminal branches of
the tibial nerve are the medial and lateral plantar nerves. Briefly, the tibial nerve follows the popliteal
artery then the posterior tibial artery and finally the medial and lateral plantar arteries.
The common peroneal (fibular) nerve divides into a superficial and a deep peroneal nerve at the head
of the fibula. Distally the superficial peroneal nerve is found in the peroneal compartment and the deep
peroneal nerve in the extensor compartment of the leg, respectively.
Femoral nerve: exits the pelvis through the lacuna musculonervosa of the subinguinal hiatus and gives
arise to several small branches supplying the extensor muscles of the thigh. A cutaneus branch, the
saphenous nerve, enters the adductor canal, but before reaching the popliteal fossa, the nerve pierces the
vasto-adductor membrane and becomes superficial on the medial aspect of the knee and courses down on
the medial surface of the leg and terminates around the medial ankle.
Crucial anatomical regions of the lower limb
A) Subinguinal hiatus
B) Iliopectineal fossa
C) Femoral canal
D) Femoral triangle
E) Adductor canal
F) Popliteal fossa
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